A Review of Six Years of Statewide Testing for Acute HIV in North Carolina

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Hi, my name is JoAnn Kuruc. I work with the University of North Carolina [UNC] in Chapel Hill. I also work along with the state of North Carolina, Department of Public Health. We have been screening for acute HIV for six years in the state of North Carolina. My poster basically summarizes the past six years.1

What happens is anybody who tests HIV negative, EIA [enzyme immunoassay] negative or indeterminate is then pooled for RNA [ribonucleic acid]. Those who are EIA negative and RNA positive are found within 72 hours of the testing by disease intervention specialists, and brought in to care at either UNC or a referral site across the state.

JoAnn Kuruc, M.S.N., R.N.

For people who test EIA indeterminate, we also do individual RNA testing to find out if they possibly could be acute cases of HIV and we would do a referral into care immediately for them. So over the past six years, we've had changes in the type of testing we use. We've gone from second-generation EIA testing to third-generation EIA testing. We also now have Aptima HIV RNA testing, which is a FDA-approved [U.S. Food and Drug Administration] qualitative assay produced by Gen-Probe.

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Initially, when we were doing the testing, a lot of our patients were EIA negative. No antibody detected a RNA positive. But now with the use of the third generation test, we're finding people who are more an indeterminate range -- where they're EIA positive, in either a negative or indeterminate western blot with a positive RNA.

Across the state, we tested a total of 891,210 people, and have had 125 acutes diagnosed over the six-year period of time. It's been significant in the fact that it increased the overall case identification of HIV in the state by 3.2%.

We found that acutes were younger. They were more likely to be men and they were more likely to be MSM [men who have sex with men] compared to those with chronic HIV infection. Though the proportion of voluntary counseling and testing and chronic HIV populations with these characteristics remains stable over time, the acute population was more dynamic.

Related to the acute population, 28% of all the acutes were adolescents, but 51% of those identified in the last two years, in 2007 through the end of 2008 [were adolescents]. Adolescent acutes were predominately MSM of color compared to those MSM of color who were diagnosed as adults. Only 21% of our population of acutes are female. The median age was 30 and they're mostly African American. Three of those diagnosed were pregnant.

These three cases actually led to changes in state law in North Carolina for the testing of HIV twice in pregnancy, once when people are initially diagnosed, and then during the third trimester. Women were more likely to have an STD [sexually transmitted disease] within eight weeks of their acute HIV diagnosis compared to men.

Can you explain the significance of that discrepancy?

I don't know if I actually know the exact reason for it. This is publicly funded testing area, so upwards of about 60% of all our acute HIV diagnosis come out of STD clinics. So it's possible that more women are going in for STD testing, not that they're sick. Or they're going in to physicians for care, but they might have an STD that needs treatment. That's where they're picked up, as opposed to maybe going in because they're sick or something like that. I don't have a scientific reason for it.

We actually got all this information and have just been compiling it and looking at it. We're still in the process of breaking it all down, and looking more deeply into each of the things.

Why do you think that acute HIV infections have declined?

That is something that's a very, very good question. It's something that's puzzled us. I don't think that acute HIV infections have declined insomuch as our testing population have increased dramatically. Initially, when we first started the program way back in 2003, we were doing about 120,000 tests statewide. I think this year we're supposed to be up around 210,000 tests. Also, with the mandated CDC-required [Centers for Disease Control and Prevention] testing, our clinics across the state are getting more proficient in testing.

The numbers of people tested in lower-risk populations, maybe confounded the numbers, but I don't think the numbers are decreasing as much. I think it remains the same because case identification in 2003 was 3.3%. So the number of people tested hasn't changed significantly, it's just the proportions have changed.

Do you think North Carolina is the only state that's using statewide screening and testing for acute [HIV infections]?

Yes.

Do you know if there are plans to emulate the program in other states, maybe in California or Florida where there are a lot of infections?

I know other states have been interested, Colorado. I think there's New York State. It's more cities or areas that do do it. I think Texas has been looking into it. I think San Francisco, areas of San Francisco do it. Areas of Washington, around Seattle, do it. I think Vancouver, British Columbia, does it. There are probably more places that I'm not sure because this is a state-funded program, so when other states are interested, it's usually through the state level. I'm the researcher on the side of North Carolina. I'm manager-in-residence, so I'm not always involved with all the things that they do. I know that they have gone to Colorado and New York, and I think Illinois, Texas and other places.

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